|Treading carefully: a qualitative ethnographic study of the clinical, social and educational uses of exercise ECG in evaluating stable chest pain.|
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|PMID: 22318662 Owner: NLM Status: In-Data-Review|
|OBJECTIVE: To examine functions of the exercise ECG in the light of the recent National Institute for Health and Clinical Excellence guidelines recommending that it should not be used for the diagnosis or exclusion of stable angina.
DESIGN: Qualitative ethnographic study based on interviews and observations of clinical practice.
SETTING: 3 rapid access chest pain clinics in England.
PARTICIPANTS: Observation of 89 consultations in chest pain clinics, 18 patient interviews and 12 clinician interviews.
MAIN OUTCOME MEASURE: Accounts and observations of consultations in chest pain clinics.
RESULTS: The exercise ECG was observed to have functions that extended beyond diagnosis. It was used to clarify a patient's story and revise the initial account. The act of walking on the treadmill created an additional opportunity for dialogue between clinician and patient and engagement of the patient in the diagnostic process through precipitation of symptoms and further elaboration of symptoms. The exercise ECG facilitated reassurance in relation to exercise capacity and tolerance, providing a platform for behavioural advice particularly when exercise was promoted by the clinician.
CONCLUSIONS: Many of the practices that have been built up around the use of the exercise ECG are potentially beneficial to patients and need to be considered in the re-design of services without that test. Through its contribution to the patient's history and to subsequent advice to the patient, the exercise ECG continues to inform the specialist assessment and management of patients with new onset stable chest pain, beyond its now marginalised role in diagnosis.
|Helen Cramer; Maggie Evans; Katie Featherstone; Rachel Johnson; M Justin S Zaman; Adam D Timmis; Harry Hemingway; Gene Feder|
|Type: Journal Article Date: 2012-02-08|
|Title: BMJ open Volume: 2 ISSN: 2044-6055 ISO Abbreviation: BMJ Open Publication Date: 2012|
|Created Date: 2012-02-09 Completed Date: - Revised Date: -|
Medline Journal Info:
|Nlm Unique ID: 101552874 Medline TA: BMJ Open Country: England|
|Languages: eng Pagination: e000508 Citation Subset: -|
|Academic Unit of Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK.|
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Journal ID (nlm-ta): BMJ Open
Journal ID (publisher-id): bmjopen
Journal ID (hwp): bmjopen
Publisher: BMJ Group, BMA House, Tavistock Square, London, WC1H 9JR
© 2012, Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Received Day: 20 Month: 10 Year: 2011
Accepted Day: 21 Month: 12 Year: 2011
collection publication date: Year: 2012
Electronic publication date: Day: 8 Month: 2 Year: 2012
pmc-release publication date: Day: 8 Month: 2 Year: 2012
Volume: 2 Issue: 1
E-location ID: e000508
PubMed Id: 22318662
Publisher Id: bmjopen-2011-000508
|Treading carefully: a qualitative ethnographic study of the clinical, social and educational uses of exercise ECG in evaluating stable chest pain Alternate Title:Uses of the exercise ECG in evaluating stable chest pain|
|M Justin S Zaman3|
|Adam D Timmis4|
1Academic Unit of Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
2School of Nursing and Midwifery Studies, Cardiff University, Cardiff, UK
3Department of Epidemiology and Public Health, University College London, London, UK
4Department of Cardiology, Barts and the London NHS Trust, The London Chest Hospital, London, UK
|Correspondence: Correspondence to Dr Helen Cramer; email@example.com
Internationally, the exercise ECG is the most common initial test for the evaluation of stable chest pain and has been used widely for almost half a century.1 In the UK, exercise ECGs are a routinely performed, central part of patient assessment in most chest pain clinics, the main site of initial specialist referral.2
The 2010 UK National Institute for Health and Clinical Excellence (NICE) guidelines recommend that exercise ECGs should no longer be used to diagnose or exclude stable angina in patients.3, 4 This recommendation is based on systematic reviews showing that other investigations have greater diagnostic accuracy5–8 and may be more cost effective at detecting people who are subsequently found to have coronary artery disease.9 NICE recommends that the diagnosis of angina be based on clinical assessment alone or clinical assessment plus either anatomical imaging (eg, coronary angiogram) or functional testing (eg, stress echocardiography).
Medical technologies can have many functions beyond their explicit purpose.10 Although technologies can distance the clinician from the patient, in some clinical settings, they may facilitate a closer relationship.11 Technologies, including diagnostic tests, are not neutral; they embody specific cultural values and a range of implicit and explicit functions.12–14 Ethnographic15 and sociological16 investigation of medical diagnosis reveals that this is a complex and often problematic process, in which the clinician combines results of diagnostic tests with the patient's narrative (structured as a clinical history), implicitly or explicitly forming, weighing up and testing hypotheses.17 Clinical assessment and diagnosis takes place in specific settings in the context of a discursive and often physical relationship between clinician and patient. Guidance to clinicians needs to be informed by an understanding of this relationship and the clinical work of patient assessment, as well the diagnostic accuracy of symptoms, signs and tests.
Given the widespread use of the exercise ECG in assessments of patients with stable chest pain, this paper seeks to understand its role in the light of emerging evidence about its poor performance as a diagnostic test. This paper reports on the functions of the exercise ECG in UK chest pain clinics, highlighting those uses that go beyond its diagnostic function.
This ethnographic study is part of a pilot for a randomised controlled trial of an intervention to improve chest pain diagnosis and management.18 Participants were staff and patients in three English chest pain clinics: a provincial city centre hospital (A), a suburban city hospital (B) and a London hospital (C). These three hospitals were selected as contrasting sites in terms of the structure of their clinics, the ethnic diversity of their surrounding population and their engagement with research studies.
A total of 89 consultations between clinicians and patients with new onset stable chest pain were observed (by HC and ME) from July 2009 to June 2010. A sampling strategy of maximum variation was used to interview a range of clinicians (see table 1) about their current working practices, decision-making processes and the role of different tests. A subset of patients were interviewed after the consultation to examine their experiences of the clinic, their understanding of the advice given and any behavioural changes they planned to make following their consultation.
Half of the clinic consultations and interviews were audio-recorded and transcribed verbatim, half were recorded in detailed field notes. To distinguish in the text between the different types of data collection technique and data recording method, the following conventions are used: all data collected by interview are indicated by (I); all data collected by observation are indicted by (O); audio-recording is indicated by (R) and the text for audio-recording is in quotation marks; data recording by written notes is indicated by (N) and the text for written notes is in italics. Data analysis was thematic, based on the constant comparative method19 aided by the data management programme ATLAS ti.20 HC and ME met regularly during the analysis to support consistency in coding; other members of the team (GF, KF and RJ) participated in further analysis. The analysis of the observational data was supplemented by and triangulated with data from staff and patient interviews.
In two of the three clinics (A and B), all patients who were able to do so performed an exercise ECG supervised by the clinician who took their initial history. In clinic C, exercise ECGs were only requested for selected patients and supervised by cardiac technicians.
Walking on the treadmill often stimulated symptoms that the patient had articulated in their initial account to the clinician and helped clarify the history (box 1, quotes 1 and 2). The clinician asked further questions and the patient elaborated details, often enabling them to distinguish between different types of chest pain. In some cases, the precipitation of symptoms such as palpitations on the treadmill supported the exclusion of angina (box 1, quote 3). Performance of exercise was also used to interrogate or contest other aspects of the history. For example, a 62-year-old man (P401, nurse S214 Hospital A (ON)) described himself as a ‘frequent walker’, however, had difficulty walking on the treadmill even at the slowest pace and incline (see also box 1, quote 4).
Testing patient histories when wired up
The language clinicians used when talking about the exercise ECG to patients was frequently that of evidence, certainty and diagnosis. For example, it could be angina and the treadmill test will quantify this (nurse S214, P401 Hospital A (ON)) and it looks normal, we got your heart rate up and no evidence that your heart is struggling (nurse S232, P130 Hospital B (ON)). Trust in the diagnostic value of the exercise ECG is further reflected in the emphasis given to test results in discharge letters to general practitioners, for example, ‘Results: This represents a positive exercise stress test. This result is diagnostic of CHD’ (Hospital A). Generally, the exercise ECG was seen as a useful initial investigation: “as a first test you can't beat that” (Doctor S117 Hospital A (IR)). Most clinicians also commented on limitations of the exercise ECG (box 2, quote 1). Nevertheless, despite universal acknowledgement of the history's central role in diagnosis, clinicians expressed uncertainty and discomfort when the results of the exercise ECG contradicted rather than confirmed a patient's history of typical angina (box 2, quote 2).
Trust in exercise ECG as diagnostic aid
In many cases, the exercise ECG had an important role in reassuring patients when the clinicians thought that they had excluded a diagnosis of angina (box 3, quote 1). In cases such as this, performance of the test facilitated immediate reassurance and reinforced the message to patients that the pains they were experiencing were not symptoms of an underlying heart problem and it was safe for them to exercise (box 3, quotes 2 and 3). In patients given a diagnosis of angina, using the exercise ECG facilitated the explanation of the diagnosis. This was based on the experience of symptoms during the test and of the clinician's response to the test output (box 3, quote 4).
Patient involvement in the diagnostic process
The exercise ECG engaged patients directly in physical activity while being monitored by the clinician and via electrocardiography. This physical engagement of the patient through the expression and clarification of their symptoms, as well as their ability to watch the clinician's expression while observing their performance precipitated further dialogue (box 3, quote 5) and informed the shape and content of reassurance at the end of the assessment.
Performance of the exercise ECG gave the clinicians a context within which to recommend increase in exercise, change in diet and smoking cessation. Poor exercise performance was the basis of exercise and dietary advice in relation to weight loss. The exercise ECG performance was also used to reinforce healthy behaviours and the primary prevention of coronary artery disease (box 4, quotes 1, 2 and 3). Patients with a non-cardiac diagnosis tended to receive exercise, diet and smoking advice, whereas the focus with patients likely to have an angina diagnosis was on the next test.
Facilitating behavioural advice
As with diagnosis and reassurance, performing the exercise test opened up opportunities for discussion: “[I]t's live and I can explain as it's happening” (nurse S214, Hospital A (IR)). One clinician advised currently heart rate going steadily shows a good base level fitness…stop smoking (nurse S214, P101Hospital A (ON)) and what I see: heart rate gone up quickly and shows she is unfit, so will need to talk about stamina training (P337—comment made through an interpreter). While the patients were on the treadmill, clinicians were also able to refer to their walking to demonstrate the intensity of exercise they should be doing (box 4, quote 4) and to reassure them that it was safe to exercise (box 4, quote 5).
The exercise ECG necessitates the removal of clothes on the top half of the body and performing exercise in front of the clinician seems to prompt specific advice on exercise and weight loss (box 4, quote 6). Several patients after walking on the exercise ECG remarked that the treadmill experience or symptoms induced during the test and the discussion with the clinician had been important for them (box 4, quote 7). The strangeness of the hospital environment may also mean that the exercise ECG had a potentially greater impact on a patient being receptive to hearing advice about behavioural changes (box 4, quote 8). However, while some patients remarked in interviews afterwards that they fully intended to make changes in diet and exercise, others clearly expressed that they had no intention to do that.
Not all clinicians used the performance of the exercise ECG to give educational advice. When interviewed, some clinicians said that they thought lifestyle advice was important, but did not offer it consistently in practice. Within clinic C, where the exercise ECG was not routinely performed with all patients (hospital C) and was not supervised by the clinician who took the patient's history, one clinician expressed frustration at the lack of opportunities to give lifestyle advice (box 4, quote 9).
We have shown that in patients with new onset stable chest pain the exercise ECG has a role in articulating the clinical history through stimulating symptoms, such as chest pain and breathlessness, and prompting additional narrative details about their symptoms. For patients in whom angina is discounted, walking on the treadmill is used to reassure them that their symptoms are not cardiac in origin and that it is safe to exercise. Performing the exercise ECG gives patients an active physical role in the diagnostic process. During and after the exercise ECG, a context is provided within which the clinician can give specific advice on exercise, weight loss, diet and smoking cessation. If clinicians use the full potential of the exercise ECG, they may also draw on the patients' experience of walking on the treadmill to demonstrate appropriate levels of exercise and the amount of breathlessness they should be experiencing to improve their fitness. These specific benefits arise from exercising in front of the clinician and are not a function of the additional time spent with the patient.
Through the exercise ECG both patients and clinicians have the opportunity to become engaged experientially, transcending the test's diagnostic function, particularly when the clinician is present and able to supervise the test. This engagement is not usually present in functional tests for coronary artery disease that has better diagnostic accuracy, such as radioisotope scanning, stress ultrasound or MRI, because even when exercise is the stressor, the test is almost invariably removed in time and place from the clinic setting. Although some clinicians talked about the additional functions of the exercise ECG, many of these were implicit and emerged from our observations. Most of the clinicians we observed believed that the exercise ECG did contribute to their diagnostic decisions,21 and so it is ironic that just as we were observing the exercise ECG at the centre of demonstrating professional authority and expertise, the legitimacy of that tool was being removed by NICE. Most clinicians also recognised the prognostic value of the exercise ECG when asked directly in interview, but this was not reflected in our observations of their clinical practice.
In this ethnographic study of chest pain clinics, we have shown that the exercise ECG was being used for a range of clinical, psychosocial and educational purposes that potentially benefit patients. These benefits would be lost if the wider functions of the exercise ECG were not implemented through other means once the exercise ECG is phased out of the assessment of patients with new onset stable chest pain in line with the UK NICE chest pain guidelines. However, loss of its wider functions is not inevitable if a way is found to integrate the exercise stress used in more contemporary functional tests with the evaluation of the patient in the chest pain clinic.
Either with clinical assessment alone or assessment using other diagnostic technologies, patients may find themselves in a passive and physically static role in the absence of a supervising clinician. There will, for example, be no opportunities for patients to walk briskly on a treadmill stimulating symptoms and no opportunities for patients to use their experiences when walking to engage in a dialogue of questions and clarification. This will weaken the embodied22, 23 and performance aspect of chest pain diagnosis24 that goes beyond verbal exchanges.16 The communication of pain is often difficult25 and complicated by differences in gender26 and ethnicity. Communicating chest pain is associated with additional anxieties.27, 28 As other studies have shown,29 successful reassurance hinges on clinicians being able to indicate that they have understood a patient's current situation and can communicate this in the consultation. Our study suggests that through physical engagement the exercise ECG can facilitate communication between patient and clinician which, even if not improving diagnostic accuracy, does enhance subsequent reassurance.
Another important feature of exercise testing in two of the clinics we observed was the presence of the clinician making the assessment, often a senior nurse practitioner or staff grade cardiologist. This is not generally the case with other functional tests for angina which are conducted by a technician in a different space from the clinical assessment by a clinician. The splitting of a diagnostic test from the wider clinical assessment may affect the potential depth of the relationship30 and the potential to clarify the clinical history through engagement with the test, particularly if this involves exercise.
A strength of our study is its ethnographic design incorporating the observation of patient–clinician consultations and combining these data with interviews: we knew what participants did as well as said. Looking at this gap between what people say they do and what they actually do is especially important when exploring what lies beneath the rhetorical use of technologies to how they are used in everyday practice. The fieldwork was undertaken at a key time just before the introduction of the NICE guidelines and therefore provides an understanding of current practice that can inform their implementation. A further strength is the combination of multiple perspectives from the wider research team of cardiologists, social scientists, health service researchers and epidemiologists. A limitation of our study is that data were collected largely from two chest pain clinics, potentially limiting the transferability of the findings, although the clinicians in the research team thought that the clinics were not atypical compared to others had experienced. Another limitation, due to time restrictions in the clinics, is that it was rarely possible for clinicians to talk through their decision making for each patient, which would have deepened our understanding of the role of the exercise ECG in this process.
As governments and professional bodies revise guidelines, the exercise ECG will have a diminishing role in the diagnosis of angina. However, many of the practices that have been built up around the use of the exercise ECG are potentially beneficial to patients and need to be considered in the re-design of chest pain assessment services without that test. In particular, the supervised exercising of patients, even if this does not explicitly inform diagnostic decisions or prognostic judgements, should form part of the assessment process.
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To cite: Cramer H, Evans M, Featherstone K, et al. Treading carefully: a qualitative ethnographic study of the clinical, social and educational uses of exercise ECG in evaluating stable chest pain. BMJ Open 2012;2:e000508. doi:10.1136/bmjopen-2011-000508
Contributors: GF, HH and ADT designed the programme of research in which this study is embedded. GF and KF had the idea for the qualitative component of the study. HC and ME undertook the interviews, observations, analysed and interpreted the data, which were discussed with KF and GF. HC wrote the first draft. GF, KF, HH, MJSZ, ADT and RJ revised the article for important intellectual content. All members of the team gave final approval of the version published. GF and HC are the guarantors. All contributors had full access to all the data in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.
Funding:This work is supported by the National Institute for Health Research (NIHR) programme grant reference RP-PG-0407-10314 (NIHR, Room 132, Richmond House, 79 Whitehall, London SW1A 2NS, UK). The NIHR had no involvement in the research process or writing of this article.
Competing interests: All authors have completed the unified competing interest form at http://www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare (1) no financial support for the submitted work from anyone other than their employer, except ADT who previously had support from NICE for work on guideline development; (2) no financial relationships with commercial entities that might have an interest in the submitted work; (3) no spouses, partners or children with relationships with commercial entities that might have an interest in the submitted work and (4) no non-financial interests that may be relevant to the submitted work.
Patient consent: We used our own ethics approved consent form.
Ethical approval: The study was approved by the West London NHS multicentre research ethics committee (08/H0709/85).
Provenance and peer review: Not commissioned; externally peer reviewed.
Data sharing statement: There is no additional data available.
We thank all the patients and clinicians who gave their time and shared their experiences and opinions with us. We would especially like to thank Jenny Tagney for all her support and enthusiasm for this project.
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Summary of data collected
|Hospital A||Hospital B||Hospital C||Total|
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